Prior Authorization for 2017

Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines to ensure medical necessity and appropriateness of care are met prior to services being rendered. We use prior authorization, concurrent review, and post-review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and facilities being provided. This is known as utilization management.

Check which services and supplies require Prior Authorization in the categories below:

Durable Medical Equipment, Supplies and Prosthetics

Fully Integrated Managed Care/Behavioral Health Services only

Professionally Administered Medications 

Inpatient, Outpatient, and Specialty Services

Mental Health Services

Pharmaceutical Formulary (any drug not listed in the formulary will require prior authorization)

Radiology, Surgical Procedures, and Transplants

  • All clinical trials require prior authorization
  • All experimental or investigational drugs and services require prior authorization
  • All genetic counseling or testing not related to pregnancy requires prior authorization (may also require additional forms, found below)
  • All inpatient and outpatient substance use disorder treatment for Medicare patients requires prior authorization
  • All unlisted codes with a charge greater than $500 require a prior authorization

Services for a specific program may not be a covered benefit. Please verify online at https://hip.chpw.org, contact Customer Service, or consult the Member Benefit Grids.

Prior Authorization Code List

2017 Summary of Changes

FIMC Prior Authorization Code List 

FIMC Prior Authorization Crosswalk

Submitting a Prior Authorization Request

Request a Care Management Portal account to check eligibility and authorization status, print approval  letters, and submit requests online 24/7. For assistance, call (206) 652-7178.

  • Fax: Fill out the form matching your request and fax to the number listed on the form.

Prior Authorization Request Forms (PDF)

2016 Documents

How CHPW determines prior authorization

Community Health Plan of Washington and its providers use guidelines for care written by experts in the field of medicine and behavioral health. These guidelines help providers know when to use certain treatments and what problems to look out for.

These resources can include Milliman Care Guidelines®, Medicare coverage determinations, national standards, the expertise of board-certified practitioners in applicable specialties, and Community Health Plan of Washington clinical coverage criteria documents.

We follow these rules:
• Utilization Management decision makers approve or deny based only on whether the care and service are appropriate and whether the care or service is covered.
• Community Health Plan of Washington does not reward providers or others for denying coverage or care.
• Community Health Plan of Washington does not offer financial incentives to encourage Utilization Management decision makers to make decisions that result in under-using care or services.

Community Health Plan of Washington staff is available to discuss this process. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization or denial at 1-800-440-1561.

Read more about our Utilization Management or contact us with questions.